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Journal ArticleDOI

Effects of haemoglobin normalization on quality of life and cardiovascular parameters in end‐stage renal failure

01 Sep 2000-Nephrology Dialysis Transplantation (Oxford University Press)-Vol. 15, Iss: 9, pp 1425-1430
TL;DR: There may be a significant haemodynamic and symptomatic advantage in maintaining a physiological [Hb] in haemodialysis patients, and a substantially higher dose of epoetin is required to maintain this level.
Abstract: BACKGROUND: The optimal haemoglobin concentration ([Hb]) for patients with end-stage renal failure is uncertain. In particular, it is unclear whether Hb normalization may be an advantage to such patients who are otherwise well. METHODS: A prospective, randomized, double-blind cross-over study was completed in 14 haemodialysis patients (12 male) aged between 23 and 65 years over a period of 18 months, using a variety of measures to examine the effect of epoetin at target [Hb] of 10 g/dl ([Hb](10)) and 14 g/dl ([Hb](14)). Patients were randomized to maintain one or other of the target levels for 6 weeks before being crossed over to the alternative [Hb]. Baseline data (mean [Hb]: 8.5+/-0.2 g/dl) were also included selectively. Six patients were known to be hypertensive. Comparisons were made between 24-h ambulatory blood pressure levels (ABP), echocardiographic findings and estimates of blood volume (BV), plasma volume (PV) and Hb mass. Quality of life estimates were obtained using the Sickness Impact Profile (SIP), and epoetin dosage requirements at target [Hb] were assessed. RESULTS: Daytime and nocturnal ABP (systolic and diastolic) were not different at the respective target [Hb], although nocturnal diastolic levels were higher compared with baseline (73+/-4 mmHg) at both [Hb](10) (83+/-3, P:<0.01) and [Hb](14) (81+/-6, P:<0.05). Significant reductions in cardiac output (5.2+/-0.3 vs 6.6+/-0.5 l/min, P:<0.01) and left ventricular end-diastolic diameter (4.8+/-0.2 vs 5.2+/-0.2 cm, P:<0. 001) were found at [Hb](14) compared with [Hb](10). Left ventricular mass index was correlated with both PV (P:<0.001) and BV (P:<0.01), but not with Hb mass. The PV decreased as the [Hb] rose (P:<0.001) but BV remained unchanged. Quality of life was significantly improved at [Hb](14) compared with [Hb](10) for both total score (6. 5+/-1.7 vs 13.4+/-3.0, P:=0.01) and psychosocial dimension score (5. 4+/-1.9 vs 15.4+/-4.0, P:<0.01). The maintenance weekly dose of epoetin required was 80% higher at [Hb](14) compared with [Hb](10) (P:<0.001). CONCLUSION: These data suggest there may be a significant haemodynamic and symptomatic advantage in maintaining a physiological [Hb] in haemodialysis patients. Although untoward effects were not identified in this study at [Hb](14), a substantially higher dose of epoetin is required to maintain this level.

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TL;DR: The evidence for and against different treatment regimens, ranging from food fortification to intravenous iron infusions, according to availability and to need are appraised.
Abstract: Iron deficiency (ID) and related anaemia (IDA) during pregnancy are highly prevalent worldwide in both developed and developing nations although the causes are often different. At conception, many women lack sufficient iron stores to meet the increased requirements of pregnancy, which are calculated at approximately 1200 mg. Appraisal of iron status in pregnant women is problematic, however the most reliable available diagnostic test is a serum ferritin < 20 µg/L. ID is often associated with other nutritional disorders, and there is frequently a secondary cause or association. A greater oral intake is usually insufficient to meet the increased demands of pregnancy, however regular oral supplements (given either daily or intermittently) can often meet maternal needs and avoid associated neonatal complications of IDA. Over-treatment with iron should be avoided, but intravenous administration is useful when deficiency is discovered late, is severe, or if the woman is intolerant of oral formulations. This paper reviews the current literature, and addresses differences in the prevalence and causes of ID betwen developed and developing nations. It examines gestational iron requirements, distinguishes between ID and IDA, and highlights difficulties in diagnostic testing. Finally, it appraises the evidence for and against different treatment regimens, ranging from food fortification to intravenous iron infusions, according to availability and to need.

73 citations

Journal ArticleDOI
TL;DR: Control of anemia in children receiving long-term PD varies by region, ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism.
Abstract: Little information exists regarding the efficacy, modifiers, and outcomes of anemia management in children with CKD or ESRD. We assessed practices, effectors, and outcomes of anemia management in 1394 pediatric patients undergoing peritoneal dialysis (PD) who were prospectively followed in 30 countries. We noted that 25% of patients had hemoglobin levels below target (<10 g/dl or <9.5 g/dl in children older or younger than 2 years, respectively), with significant regional variation; levels were highest in North America and Europe and lowest in Asia and Turkey. Low hemoglobin levels were associated with low urine output, low serum albumin, high parathyroid hormone, high ferritin, and the use of bioincompatible PD fluid. Erythropoiesis-stimulating agents (ESAs) were prescribed to 92% of patients, and neither the type of ESA nor the dosing interval appeared to affect efficacy. The weekly ESA dose inversely correlated with age when scaled to weight but did not correlate with age when normalized to body surface area. ESA sensitivity was positively associated with residual diuresis and serum albumin and inversely associated with serum parathyroid hormone and ferritin. The prevalence of hypertension and left ventricular hypertrophy increased with the degree of anemia. Patient survival was positively associated with achieved hemoglobin and serum albumin and was inversely associated with ESA dose. In conclusion, control of anemia in children receiving long-term PD varies by region. ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism. Anemia and high ESA dose requirements independently predict mortality.

73 citations

Journal ArticleDOI
TL;DR: It is found that Hgb at initial registration is a statistically independent predictor of survival, and substantial variation in Hgb values exists at all GFR levels, and the need to study the impact of modification ofHgb at different G FR levels on survival is underscored.
Abstract: Haemoglobin (Hgb) levels are known to be associated with numerous adverse outcomes in both chronic kidney disease (CKD) and non-CKD patients. This analysis evaluates the association of baseline haemoglobin levels on survival in CKD patients, who are followed by nephrologists, irrespective of glomerular filtration rate (GFR), prior to initiation of renal replacement therapy (RRT) and erythropoietin hormone replacement therapy. Analysis of data from the provincial database (PROMIS, Patient Registration and Outcome Management Information System) in British Columbia, Canada, was undertaken. Records used for the analysis included all CKD patients at first registration: GFR <60 ml/min/1.73 m 2 , not yet on dialysis, starting from May 1998 to October 2002, and who had complete data (defined as age and gender, diabetic status, eGFR and Hgb levels). The primary objective of this study was to determine the association of Hgb and survival controlling for eGFR at first registration value, age, gender and diabetic status. Multivariate Cox proportional hazards analysis with time to death as outcome variable was performed. The cohort included 3028 patients: the mean age was 65 years, 28% were diabetic, and the mean eGFR in the cohort was 21 ml/min/1.73 m 2 . The cohort is representative of the BC CKD and dialysis population regarding ethnicity: 64% Caucasian, 32% Asian. Median follow-up was 27 months, 1 year survival was 0.92, 2 year survival was 0.85. Hgb at initial registration is a statistically independent predictor of survival (RR ¼ 0.875 for every 10 g/l, 95% CI: 0.835–0.917, P ¼ 0.0001), after adjusting for age, gender, diabetic status and baseline eGFR. Further analysis, controlling for RRT, demonstrated a similar association between Hgb and survival (RR ¼ 0.853 for every 10 g/l, 95% CI: 0.799–0.910, P ¼ 0.0001), after adjusting for above variables. Substantial variation in Hgb values exists at all GFR levels. These findings underscore the importance of evaluating Hgb at all GFR levels, and the need to study the impact of modification of Hgb at different GFR levels on survival.

69 citations


Cites background from "Effects of haemoglobin normalizatio..."

  • ...Other adverse effects include impaired cognition, reduced quality of life, sleep disturbances and decreased exercise tolerance [2,4,12]....

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Journal ArticleDOI
TL;DR: In peritoneal dialysis patients, anemia is associated with hospitalization and mortality in a manner supporting current Kidney Dialysis Outcomes Quality Initiative (K/DOQI) hemoglobin targets, and hemoglobin levels of >/=12 g/dL are associated with lower hospitalization rates in diabetic patients.

65 citations


Cites background from "Effects of haemoglobin normalizatio..."

  • ...More recent randomized trials suggest that full correction of anemia leads to further improvement in quality of life without further regression of left ventricular hypertrophy [16–18], while the only adequately powered trial to date showed no survival benefit of full correction of renal anemia, and a clear tendency toward harm in terms of dialysis access preservation [19]....

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Journal ArticleDOI
TL;DR: It is concluded that decline in kidney function is associated with a subsequent decline in health-related quality of life, particularly in terms of physical activity.
Abstract: Little research has been published assessing changes in the functional health status of children and adolescents with chronic kidney disease (CKD). We know little about which clinical parameters influence functional status or health-related quality of life in these young people. In a prospective study using data from semi-annual visits over a 4-year period from 78 adolescents with CKD aged 11 years to 18 years, we detail the impact of several clinical measures (i.e., kidney function, albumin, hematocrit, height) on short-term changes in health-related quality of life. The 50-item Child Health Questionnaire Parent Form, a validated health-related quality of life measure in children, was used to obtain physical and psychosocial functioning summary scores at each visit. After adjustment for the variables mentioned above, the physical summary score on the Child Health Questionnaire (CHQ) declined as glomerular filtration rate declined. Increasing height was associated with a positive change in physical and psychosocial summary scores. We conclude that decline in kidney function is associated with a subsequent decline in health-related quality of life, particularly in terms of physical activity.

63 citations


Cites background from "Effects of haemoglobin normalizatio..."

  • ...Although a number of clinical measures has been associated with the quality of life and an increased risk of morbidity and mortality in adults with CKD, few studies have examined this in children [18, 19, 20, 21, 22, 23, 24, 25, 26, 27]....

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References
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Journal ArticleDOI
TL;DR: In this article, the authors developed the Sickness Impact Profile (SIP), a behaviorally based measure of health status, and evaluated its reliability and validity using multitrait-multimethod technique.
Abstract: The final development of the Sickness Impact Profile (SIP), a behaviorally based measure of health status, is presented. A large field trial on a random sample of prepaid group practice enrollees and smaller trials on samples of patients with hyperthyroidism, rheumatoid arthritis and hip replacements were undertaken to assess reliability and validity of the SIP and provide data for category and item analyses. Test-retest reliability (r = 0.92) and internal consistency (r - 0.94) were high. Convergent and discriminant validity was evaluated using the multitrait--multimethod technique. Clinical validity was assessed by determining the relationship between clinical measures of disease and the SIP scores. The relationship between the SIP and criterion measures were moderate to high and in the direction hypothesized. A technique for describing and assessing similarities and differences among groups was developed using profile and pattern analysis. The final SIP contains 136 items in 12 categories. Overall, category, and dimension scores may be calculated.

4,283 citations

Book
01 Feb 1994
TL;DR: In this paper, the principles of exercise testing and interpretation are presented for exercise testing in the Libros de Medicina (Patologia) 5/e - Patologia - 139,00
Abstract: Principles of Exercise Testing and Interpretation, 5/e - Libros de Medicina - Patologia - 139,00

2,331 citations

Journal ArticleDOI
TL;DR: In patients with clinically evident congestive heart failure or ischemic heart disease who are receiving hemodialysis, administration of epoetin to raise their hematocrit to 42 percent is not recommended.
Abstract: Background In patients with end-stage renal disease, anemia develops as a result of erythropoietin deficiency, and recombinant human erythropoietin (epoetin) is prescribed to correct the anemia partially. We examined the risks and benefits of normalizing the hematocrit in patients with cardiac disease who were undergoing hemodialysis. Methods We studied 1233 patients with clinical evidence of congestive heart failure or ischemic heart disease who were undergoing hemodialysis: 618 patients were assigned to receive increasing doses of epoetin to achieve and maintain a hematocrit of 42 percent, and 615 were assigned to receive doses of epoetin sufficient to maintain a hematocrit of 30 percent throughout the study. The median duration of treatment was 14 months. The primary end point was the length of time to death or a first nonfatal myocardial infarction. Results After 29 months, there were 183 deaths and 19 first nonfatal myocardial infarctions among the patients in the normal-hematocrit group and 150 deat...

1,944 citations

Journal ArticleDOI
TL;DR: It is concluded that clinical and echocardiographic cardiovascular disease are already present in a very high proportion of patients starting ESRD therapy and are independent mortality factors.

1,255 citations

Journal ArticleDOI
TL;DR: Overstretching appears to be coupled with oxidant stress, expression of Fas, programmed cell death, architectural rearrangement of myocytes, and impairment in force development of the myocardium.
Abstract: To determine the effects of loading on active and passive tensions, programmed cell death, superoxide anion formation, the expression of Fas on myocytes, and side-to-side slippage of myocytes, papillary muscles were exposed to 7-8 and 50 mN/mm2 and these parameters were measured over a 3-h period. Overstretching produced a 21- and a 2.4-fold increase in apoptotic myocyte and nonmyocyte cell death, respectively. Concurrently, the generation of reactive oxygen species increased 2.4-fold and the number of myocytes labeled by Fas protein 21-fold. Moreover, a 15% decrease in the number of myocytes included in the thickness of the papillary muscle was found in combination with a 7% decrease in sarcomere length and the inability of muscles to maintain stable levels of passive and active tensions. The addition of the NO-releasing drug, C87-3754, prevented superoxide anion formation, programmed cell death, and the alterations in active and passive tensions with time of overloaded papillary muscles. In conclusion, overstretching appears to be coupled with oxidant stress, expression of Fas, programmed cell death, architectural rearrangement of myocytes, and impairment in force development of the myocardium.

642 citations

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